A 5 y old boy was brought to our ER on the night of 19 th April with two episodes of hemetemesis in the evening. He had occasional abdominal pain for two weeks.

He was taken to a local hospital where he was given symptomatic treatment. He was severely pale and hypotensive at admission. Systemic examination showed no significant findings. USG abdomen was normal. He was admitted  to PICU and stabilised with fluids, blood transfusion and ionotropes and supportive measures. Preliminary investigations did not show any  major abnormality except severe anemia. It was planned to take him up for endoscopy in the morning.

But,  a couple of hours after admission, he had another episode of massive hemetemesis, following which he destabilised. He was  given further fluids, ionotropes were escalated and  was ventilated. A chest xray taken showed a coin shaped FB in the possibly in the esophagus. Putting together the findings….A coin shaped coin FB with hemetemesis, a button battery ingestion was suspected and emergency Gastro and CTVS consultation was sought. An emergency OGD scopy showed a button battery impacted in the oesophageal wall  with erosion of the lateral wall of the oesophagus.  Since oesophageal injury was unlikely to cause such a massive bleed, an aortic injury was suspected and the chiild was shifted for emergency CT aortogram which confirmed aortoesophageal fistula. He was taken up for emergency thoracotomy and aorto esophagal repair. Apart from the high risk of the procedure,  another challenge was arranging enough blood as the child was O-ve. 

Post surgery, his hemodynamics stabilised but as a complication of severe hypotension, he developed MODS and AKI  which necessitated peritoneal dialysis. Also, at the time of surgery it was noted that his oesophageal injury was infected. So his antibiotics were upgraded. But despite being on Meropenam, he continued to spike fever. His cultures came sterile so sepsis PCR panel was sent which came positive for Enterobacteriace NDM and VIM gene positive. Based on this,  antibiotics were upgraded to Polymyxin B and later on to Ceftazidime  Avibactum + Aztreonam due to AKI. Over the next week,  he gradually improved, and fever settled. Organ functions improved, PD was discontinued and he was extubated after 5 days. Meanwhile, nasojejunal tube was inserted endoscopically and he was initiated on NJ feeds. All lines, drains and catheters were removed. He seemed to be gradually improving. But suddenly on the 12 th admission night he had another episode of hypotension and bleeding. We were back to square one. He was once again taken up for emergency thoracotomy. This time it was chemical necrosis of aorta and esophagus. The necrotic area of the aorta was resected and anastamosis done and oesophagus was repaired. This time, he was extubated after 24 hrs. Feeds were restarted. But he developed features suggestive of refeeding syndrome including severe electrolyte imbalances ( hypokalemia, hypomagnesemia, hypophosphatemia)which was managed over the next few days. Feeds were slowly escalated and he was gradually mobilised. On D21 after his 2nd surgery,  a contrast esophagogram was done which showed no leak. So, oral fluids were started on D22 which was slowly escalated to soft diet and then to solids. His NJ tube  was removed on D35. He remained in the hospital for 40 days.

Literature review showed that in a large retrospective data of 1.3 lakh children only 14 developed major vessel injury. As per data from National Capital Poison Centre , out of 28 cases of Aortoesophageal fistula from 1977-2019 there were only 5 survivors. There are 2 case reports of survival after 2019. There is no consolidated data available from India.

This was a multidisciplinary effort involving Pediatric ICU and Pediatrics, Nursing, CTVS, Gastroenterology, Nephrology,Anesthesia, Transfusion medicine, PMR and dietetics. We are grateful to the Lord for making us instruments of His mighty work. This is the Lord's doing and it's marvellous in our eyes. Yes indeed! 

P. S - post recovery of the battery parents remembered that they had seen him playing with the battery of his broken toy watch 2 weeks ago.

PPS

Also sir I am very thankful to Dr Valsan Verghese, Ped ID Consultant from CMC, whom I had consulted frequently regarding treating the sepsis in this child. He  was very helpful and patient,even though he was in his busy OPD and the next time he was on leave. He gave a lot of guidance regarding choice of antibiotics.

Dr Shilpa Abraham is one of the few trained Pediatric Intensivist with DM Pediatric Intensive care from JIPMER

Dr Jijo Joseph

Head of Believers Advanced Centre for Pediatrics

(The only comprehensive Pediatric Centre in Kerala with 20+ Pediatric specialities)

Along with our Pediatric Cardiothoracic Team (Believers International Heart Center)

Dr John Valliath FRCS  Pediatric Cardiothoracic Surgeon

Dr Suresh Kumar Pediatric Cardiologist

Dr Sajith Sulaiman Pediatric Cardiac Anaesthetist

Dr Benson Pediatric Cardiac Anaesthetist